Licensure, Compliance, Regulatory Practice & Enforcement Group

Community HealthChoices Contracting

Long-term care providers in the Commonwealth face continued reimbursement challenges under Community Health Choices Managed Care. Fortunately, Capozzi Adler is available to assist your facility with negotiating contracts with the CHC-MCOs.

Background on Managed Care in Pennsylvania:
During the continuity of the care period, which is a period of 18 months from implementation, DHS mandates that the CHC MCOs contract with all existing Medicaid certified nursing facility providers if those nursing facility providers are willing to do so and are willing to accept the Community HealthChoices rates for payment. During this transition period, the CHC MCOs have agreed to pay providers a “rate floor” for the first three years after implementation of CHC in the region, which consists of an average of the four quarterly Medicaid rates effective prior to the date of implementation in the region.

Now that all of the Commonwealth has entered into Community Health Choices Medicaid Managed Care effective January 1, 2020 in the “Other Region” and CHC has now entered “steady state” operations, the long term care provider community must turn its attention to what is next for Medicaid Managed Care. The “any willing provider” period expired for the Southwest Region on June 30th 2019, expired for the Southeast region on June 30th, 2020 and expires for the rest of the Commonwealth on June 30th, 2021. After the “any willing provider” period expires in each region providers will essentially be on their own as to whether they will be able to contract with one or all three of the CHC MCOs. Moreover, after the end
of the rate floor, providers will again be completely on their own with respect to negotiating their rates for Medicaid recipients, with essentially private entities that are the CHC MCOs. The rate floors will no longer exist.

Rate floors have not kept pace with increased acuity of patients/ residents being served by providers, or the increased costs of providing that care. Not only have the rate floors not kept pace with costs, but payment methods will need major adjustments to take into account the demonstrated increased cost of infection control compliance from the ongoing COVID-19 pandemic and the projected enhanced licensing and certification (including OSHA) requirements, as well as increased insurance and staffing costs, expected to follow from it.

If you have questions on Managed Care in Pennsylvania or if you would like assistance in negotiating your contracts, please contact Daniel Natirboff, Esquire at or 717-233-4101.

Continuing Care Retirement Communities (CCRCs)

CCRCs, as hybrid providers of a continuum of services, face legal and regulatory issues not confronted by free-standing long-term care providers. Our attorneys can help a CCRC develop residency agreements and respond to the wide variety of legal challenges. We can also assist in resolving the regulatory and structural issues related to developing a CCRC.

At Capozzi Adler we understand the regulatory framework of the Insurance Department and are familiar with its regulators. We were Counsel for the CCRC in the successful and precedent-setting Chapel Pointe case. In that case, the Pennsylvania Supreme Court held that Chapel Pointe’s CCRC was exempt from the payment of all real estate taxes beginning in 2001.

Corporate Compliance Services

At Capozzi Adler, we’re a leader in health care compliance, particularly in the long-term care field. Our firm began implementing corporate compliance programs for our long-term care clients even before the Department of Health and Human Services’ Office of Inspector General issued its voluntary Compliance Guidance for nursing facilities. Today, our leading-edge, proactive approach remains intact. We continually seek the newest and best practices in health care compliance, and we assist our clients in implementing those practices in a careful, cost effective manner.

Sales and Acquisitions of Nursing Facilities

In numerous transactions, our firm has acted as special or corporate counsel, including those involving acquisitions of facilities in bankruptcy. We work to structure transactions to enhance Medicare/Medicaid reimbursement and to streamline the regulatory approval process. We also advise clients on how best to address Union collective bargaining agreements, including negotiating new agreements and eliminating exposure for the prior owner’s past employment practices. During the week of July 1, 2011, we successfully closed over $30 million in sales for our clients.

Special or General Counsel to Health Care Providers

At Capozzi Adler, P.C., we assist with the general and corporate issues every business, including health care providers, must confront. We’ve assisted with restructuring some of our clients to better position themselves for the risks and challenges of the changing health care system. By doing so, we’ve helped clients to pursue participation in joint ventures and to diminish the risk associated with expanding into new service areas.

We also provide special assistance to our clients by updating existing policies and practices, including employee manuals, and drafting admissions agreements and other contracts that meet program and licensure requirements. In addition, we provide assistance with obtaining timely collections and the resolution of disputes, and we help our clients with the development of home and community based service programs. To help clients respond to the ever-changing health care delivery system, we also assist them in their strategic planning efforts.

Survey and Enforcement

Capozzi Adler, P.C. offers broad experience in assisting providers through the compliance, survey, and enforcement process. Our attorneys are familiar with the requirements for participation in Federal and State health care programs. We assist our clients with obtaining and maintaining required licensures and certifications while meeting compliance standards for those programs. We have assisted providers in developing effective health care policies and in responding to both State and Federal regulators.

In addition, we have worked with our clients to successfully utilize the informal dispute resolution process. Recognizing sound business sense, we work to resolve some survey disputes amicably without relinquishing the merits of the provider’s position and while preserving the provider’s appeal rights.